title: T-tube drainage versus primary closure after laparoscopic common bile duct exploration.
abstract: BACKGROUND
  T-tube drainage may prevent bile leak from the biliary tract following bile duct exploration and it offers post-operative access to the bile ducts for visualisation and exploration. Use of T-tube drainage after laparoscopic common bile duct (CBD) exploration is controversial.
  
  
  OBJECTIVE
  To assess the benefits and harms of T-tube drainage versus primary closure after laparoscopic common bile duct exploration.
  
  
  METHODS
  We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until April 2013.
  
  
  METHODS
  We included all randomised clinical trials comparing T-tube drainage versus primary closure after laparoscopic common bile duct exploration.
  
  
  METHODS
  Two of four authors independently identified the studies for inclusion and extracted data. We analysed the data with both the fixed-effect and the random-effects model meta-analyses using Review Manager (RevMan) Analysis. For each outcome we calculated the risk ratio (RR), rate ratio (RaR), or mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat analysis.
  
  
  RESULTS
  We included three trials randomising 295 participants: 147 to T-tube drainage versus 148 to primary closure. All trials had a high risk of bias. No one died during the follow-up period. There was no significant difference in the proportion of patients with serious morbidity (17/147 (weighted percentage 11.3%) in the T-tube drainage versus 9/148 (6.1%) in the primary closure group; RR 1.86; 95% CI 0.87 to 3.96; three trials), and no significant difference was found in the serious morbidity rates (weighted serious morbidity rate = 97 events per 1000 patients) in participants randomised to T-tube drainage versus serious morbidity rate = 61 events per 1000 patients in the primary closure group; RR 1.59; 95% CI 0.66 to 3.83; three trials). Quality of life was not reported in any of the trials. The operating time was significantly longer in the T-tube drainage group compared with the primary closure group (MD 21.22 minutes; 95% CI 12.44 minutes to 30.00 minutes; three trials). The hospital stay was significantly longer in the T-tube drainage group compared with the primary closure group (MD 3.26 days; 95% CI 2.49 days to 4.04 days; three trials). According to one trial, the participants randomised to T-tube drainage returned to work approximately eight days later than the participants randomised to the primary closure group (P < 0.005).
  
  
  CONCLUSIONS
  T-tube drainage appears to result in significantly longer operating time and hospital stay as compared with primary closure without any evidence of benefit after laparoscopic common bile duct exploration. Based on currently available evidence, there is no justification for the routine use of T-tube drainage after laparoscopic common bile duct exploration in patients with common bile duct stones. More randomised trials comparing the effects of T-tube drainage versus primary closure after laparoscopic common bile duct exploration may be needed. Such trials should be conducted with low risk of bias, assessing the long-term beneficial and harmful effects including long-term complications such as bile stricture and recurrence of common bile duct stones.
authors.affiliation: Department of Surgery, Royal Free Campus, UCL Medical School, London, UK. kurinchi2k@hotmail.com.
authors.forename: Kurinchi Selvan
authors.initials: KS
authors.lastname: Gurusamy
authors.forename: Rahul
authors.initials: R
authors.lastname: Koti
authors.forename: Brian R
authors.initials: BR
authors.lastname: Davidson
mesh_terms: D042883:Choledocholithiasis / Q000601:surgery*; D003135:Common Bile Duct / Q000601:surgery*; D004322:Drainage / Q000009:adverse effects* / Q000295:instrumentation*; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D007902:Length of Stay; D016032:Randomized Controlled Trials as Topic